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source of anxiety lest he should secure something dangerous in his outings, not so much with the idea of using it against his attendants as against the savages he was preparing to meet when he made his escape. He had to be constantly searched whenever he returned from an outing, and on several occasions made his escape and secured corn knives or something similar from barns and outhouses. He was by no means really dangerous, but on one or two of these occasions he succeeded, to his own satisfaction, in terrifying persons he met, and once had a whole village in an uproar. was usually easily recaptured, but his accounts of asylum treatment, when on his escapades, were enough to set up a legislative investigation, and it was not considered desirable to have him at large. As he was very evasive and cunning in his way, he several times made his escape, but was always heard from immediately, as his performances quickly revealed where he belonged. In this case, as in some other similar ones, the patient made an approximate recovery, and was not heard from again as insane, at least, not for a number of years.

In other cases we may have a senile confusional delirium, a paranoia, or circular insanity; they are simply ordinary instances of these types of insanity occurring in and colored by senility. The natural senile changes in the brain may favor any kind of mental failure in predisposed individuals or under conditions of special stress, as at other periods of life; and when they occur, put on them the special stamp of senile insanity, which is liable to be, as in the case above mentioned, a sort of childish weakness; the memories and tendencies of the earlier life still remaining and predominating over the more recent cerebral acquisitions. Thus we see in some of these cases curious tendencies to collecting rubbish, trifling objects, etc., returning, as it were, to the tastes and fancies of

childhood. The prevailing note in the senile insanities is the non-realization of the present and the renewal or survival only of the past.

It is difficult to draw any arbitrary or exact line between the functional insanities, so to speak, of the aged and those connected with gross brain disease. It is only the very evidently casual affections, influenced. by heredity acting with the mild general cerebral impairment of senility, that can be properly said to be unconnected with the graver changes. In all cases, of course, there must be senile impairment, but in these it would not have revealed itself in insanity but for these other causes. In the greater proportion the mental disorder is itself the direct cause, and the effect may show itself in the various ways above described. In addition, one or two other forms may be here mentioned, such as the hallucinatory delirium that sometimes appears in this condition, which resembles acute delirium, and may be accompanied with febrile temperature and other signs of maniacal inflammation. It is not always fatal, and is one of the features that counterfeit paresis in some of its manifestations.

The pathology of senile insanity, in a general way, may be said to be that of arterial degeneration involving the nutrition of the brain. "A man is as old as his arteries" is an approved medical saw, and, we may add, he is very often insane in proportion as his cerebral arteries are diseased. The pathologic findings correspond with this view of the nature of the condition; we have wasting of the brain, atrophy of the cells, thickening and loss of elasticity of the arterial coats, with frequent miliary aneurysms, and minute hemorrhagic effusion. In the advanced cases of these conditions we may find thickening of the membranes, evidences of old inflammations, etc., and in the gross organic cases we have hemorrhagic foci and patches of softening, and sometimes organized clots and false mem

branes. There is hardly any form of gross cerebral disease that may not reveal its old lesions in the autopsies of senile insanity. It is often the case that the outbreak or appearance of mental disease in the aged is seen as the apparent immediate result of some injury or disease that may itself leave its special traces or modify those otherwise produced.

The diagnosis of senile insanity is usually easy; the fact is that almost any appearance of mental disorder at an advanced age is apt to be so far colored by the senility as to be deserving of the name. It is only in those cases that occur comparatively early, in the sixth and seventh decades of life, that we are likely to question their proper reference. It must not be forgotten, also, that there may occur insanities in special cases of unusually vigorous individuals at a very advanced age that have nothing about them absolutely characteristic of the changes of old age. Thus, we have seen a circular insanity in an old man which was in nowise. very dissimilar to that occurring in much younger persons; it was of the severer type, with decided mania. in the exalted stage and nearly complete stupor in the depressed phase. These cases are, however, comparatively rare, and even they are not usually so free from the tinge of senility as was the one above mentioned. Melancholia in the elderly is not specially dissimilar from that in the young, though it has not so often the symptoms of extreme agitation. It is in those cases that resemble paresis that a mistake is, we think, most often made, and reference has already been made to the probable false diagnosis in many of these cases.

It is not possible to always draw the line between the ordinary symptoms of senile mental weakness that cannot properly be ranked as insanity and those of actual mental disease. This should be kept in mind; a man may be weak in memory, especially of recent events, and may, in fact, be an example of the sudden

or incipient form of dementia of old age in some respects, but still be, in the main, of "sound and devising mind," as the legal language expresses it. This is a matter of importance in will cases, and the nature of the will itself, in such instances, is often strong evidence. If it shows unreasonable likes and dislikes, or signs of delusions, it may be conclusive if sole evidence of disordered intellection. The moral defects noted in other cases, the immoralities, obscenities, financial extravagances, etc., may be the only symptoms that make us certain that the case passes over the border of sanity into that of unquestionable mental disease. The patient in this, as in other cases, must be compared with his normal self, and while allowance is made for the general and usual changes of senility,— the changes in memory, in the emotional capacity and control, any marked differences in character will go far to place it on the wrong side. It must be remembered, also, that senile delusional insanity, like that of earlier life, may develop without very observable general or special failure in other directions.

The treatment of senile insanity may be given briefly. It is mainly symptomatic. In cases of general mental failure the most that can be done is to protect the patient from injury, watch his wanderings, and attend to his bodily necessities. In the acute psychoses of old age the treatment is practically the same as in the similar forms in younger patients, due allowance being made for age and physical condition. The suicidal tendency in melancholia is to be especially guarded against, the more as it may be less evident than in younger patients. Organic dementia, and cases showing very decided atheromatous conditions of the vessels, have, of course, their own special indications and cautions. The senile dement especially needs a kindly but firm control; he is commonly easily managed, but may be very trying to his caretaker.

CHAPTER XVII.

DEGENERATIVE INSANITIES.

WE understand by the degenerative insanities that class of mental disorders associated with and caused by more or less permanent and incurable structural or functional defects, usually congenital and hereditary. We say more or less permanent and incurable because, while in the great majority of cases they are permanent and incurable, it is not intended to deny the possibility of changes taking place, under favorable conditions, such as to correct or compensate for the defects. The predisposition to insanity through general weakness or lack of resistance of the organism is, of course, not included here; the difference between the two conditions is that in the one we may have a weak or weakened brain, while in the other the condition is that of original lack of balance in some respect or other, revealing itself either in more or less serious and permanent mental aberration, or in erratic breakdowns, occurring from time to time. The one is like a machine of general inferior workmanship or worn out; the other, like one that is badly constructed in some special part, affecting its working either generally or at times. It does not necessarily follow that these insanities are always incurable, though that is their tendency; there is a possibility that the defects may be in some way compensated for and the mental workings become normal. In many instances, indeed, the degenerative defects may be only slight and the patient never entirely overstep the borderland of sanity; he may be only regarded as eccentric or a crank, or subject to moods and spells. More will be said in regard to this point when discussing some of the special